Archive for June 25, 2012

Throughout the past two weeks we have been discovering the meaning within these words that were shared with us one night over dinner with a physician from the New River Health System. “Within the clinical encounter,” Dr. Doyle said,” the meaning emerges from the interaction.” We have been taught a certain approach to patient interaction. When a patient presents to a clinic visit, we poke and prod with questions, seeking specific information. But, even with the intended good will behind our approach, something is still not working. What would happen if we handed over the control? If we stepped out of the driver’s seat and let the patient steer the conversation. What if we let go of our expectations, the drive for answers, and simply listened? William Osler, father of modern medicine, is quoted as saying, “Listen to your patients. Listen and they will tell you what is wrong with them. Listen long enough, and they will even tell you what will make them well.” Maybe what we need is a return to his philosophy; a return to oral history.

During the last few days of our stay in the West Virginian mountains, we put our final touches on the project we had been given to do. I say “our” final touches, because the work we have done is merely the foundation of an approach or tool that the Cabin Creek Health Systems (CCHS) may use to increase the effectiveness of their communication with patients. In the hopes of increasing our understanding of the Oral History approach, we split into pairs and went on home visits throughout the communities surrounding Cabin Creek. Patrick Krueger and I visited three different homes, and came away with three very different experiences. As a group we created this list of “lessons” learned and tips to conducting an effective oral history interview:

The goal of the interaction is to establish the relationship and foundation

The emphasis should always be listening

Learn to be comfortable with silence

Digressions do not exist; affirm the participants’ stories

Utilize neutral facial expressions/avoid nodding/verbalizations

Avoid the urge to use “teachable moments”; mentally note the statement for later follow-up or motivational interviewing

Keep follow-up questions or statements succinct and open

Be present; focus on the client

Respect time limitations

I would like to emphasize three of these points, one through a story, and two for their poignancy. At the first home Patrick and I visited, we spent 30 minutes listening to this woman share her struggles with diabetes and weight loss. She haltingly shared her story. But, as soon as we thanked her for her time and turned off the recorder, our true education began. In talking about her home and her hobbies, she casually mentioned her frequent use of the tanning bed in her back room. Unable to control my surprise, my mouth fell open. That, of course, raised her defenses, and we ended up doing a little risk-factor education. This was a departure from the true nature of our visit, which was to hear her story, not judge it. Utilizing neutral facial expressions is paramount. When someone is sharing their story, judgmental expressions, such as raised eyebrows, and a jaw dropped in disbelief, can effectively close the book of their lives they had so graciously opened for you to read.

We presented our findings to CCHS as a tool for their Health Coaches to use in forging a strong relationship with their clients. The aim is for the Oral History approach to be utilized on the first visit, in order to lay the foundation for more effective motivational interviewing on subsequent visits. In receiving someone’s oral history, you are being given a window into their lives. It is a beautiful way to come to truly know someone. What a better way to start a therapeutic relationship. But, in order to foster this type of openness, the interviewer needs to avoid the urge to capitalize on any and all “teachable moments.” As nurses, we have been taught to never let a opportunity for education slip by. However, in this setting especially, imparting knowledge or advice through education, however well intended, creates a power differential. So, it is imperative to hold back on those urges. Make mental notes only. And simply continue to listen, opening yourself to truly hearing their story.

Lastly – probably the hardest part of this approach – is silence. Silence is a powerful force. And under its power we saw individuals blossom. By our silence we them gave the gift of time to construct and relive their stories, and we conveyed our genuine interest in their lives. I know I have yet to reach the point where I am comfortable with silence. But, I have seen the beauty that comes out of letting that silence stretch a few moments longer than normal. Fears are confessed, joys are shared, truth emerges.

For two weeks, our team of 7 persevered through long days; hours and hours of commuting on curing country roads between the clinics, the communities, and our beautiful forest cabin. We also spent countless hours researching, conversing, and compiling our plan to present to CCHS. (If you would like to view the fruits of our labor, please visit www.oralhistorytrainingmodule.com ). We also cooked delicious meals every nights, wandered through the forested hills surrounding New River, and even spent an afternoon rafting down its turbulent waters. All in all, I believe that we came away from West Virginia changed. This experience has reshaped the way we will approach communication with our clients; to focus less on searching for the right questions to ask, and more on the relationship built, and the words that are spoken. For it is true – the meaning we are searching for emerges from the interaction we foster with being open.

Throughout the last two weeks, a majority of our mornings have been spent shadowing providers in the various clinics within the Cabin Creek and New River Health Systems. Bettina Hall, one of our group members, described this experience best; “It has been a remarkable experience. Because access to care is limited, providers have to utilize their creative and skilled efforts to offer the best and most appropriate medical care for their clients, many of whom are economically disadvantaged. I think one of the main things that has really stood out to me is the commitment and sincerity providers put into the well-being of all their patients, and its clearly evident that the patients equally value their time, and the support that they receive from the whole medical team.”

Being that we will be starting our master’s program in the fall, and a lot of us are aiming to be primary care providers, these mornings offered an exciting sneek peak into our careers. I was blessed with the opportunity to observe PAs, NPs, and MDs in action – serving their clients with the utmost compassion, perseverance, and creativity. The health care challenges that the Cabin Creek Community faces are complex; rooted in a social history of oppression and isolation. Through what amounted to hours of conversations with providers and medical assistants, nurses and aministrative staff, we discovered that the major health issues in the area were hypertension, diabetes, obesity, and depression. The vast majority of clients I saw were under an opiate contract due to the prescriptions they had for managing their chronic pain. I had conversation upon conversation with providers about how best to manage pain, and how to work with a population in which the percentage of narcotic abuse is tragically high. Both health systems are fighting this battle with perseverance. They are turning to the evidence within the literatire to offer their clients the best care possible, and to help their entire communities break free from the chains of addiction.

This is just one example of the quality of care that these clinics seek to provide. Cabin Creek Health System (CCHS) is constantly addressing the needs of their community in an innovative, honest, and team-centered manner. I was truly inspired by the unparalleled commitment to service that was exhibited by the CCHS staff. John Rice, PA.C is a prime example of this. An article about the outstanding care he give his patients was printed in the Charleston Gazette. One of their patients credited John Rice and CCHS as helping her win the fight against food, and subsequently gain back control of her health. He is committed to the health and well-being of his patients – seeing them as whole human beings worthy of respect and love. And through that he empowers them to take charge of their health and their lives. Bettina, who shadowed him for these two weeks, shared an example of the thoughtfulness and intentionality with which he approaches the relationship with his patients. He is so in-tune with his patients that he picks up the small things; nothing a patient tells him is irrelevant. A patient told him it would be their birthday the day of their appointment. So, John made him a brownie, decorated on a plate that said “Happy Birthday.” Bettina called him “a quintessential good Samaritan.” It is stories like this that truly inspire and encourage me. Providers who are working and living within their communities – serving a whole community. They are completely immersed, committed, and persevering, offering the continuity of care that is needed to effect true and sustainable change.

Happy Birthday Gift

It was in this environment that we got to spend each morning of the past two weeks – deepening our understanding of the culture and the lives of the people, through the eyes of their providers. Dr. Dan Doyle, a committed and passionate physician who has provided over 30 years of service to both the Cabin Creek and New River clinics, penned a Golden Rule of Primary Care, which is hanging in most of the clinics buildings. I will leave you with his words, and please stay tuned for more of our journey, and how we used what we learned in the clinics, combined with our oral history training, to create a plan for effective patient communication.

Week two kicked off to a great start. Clayton State dental hygiene students and new University of Georgia pharmacy students joined our group to assist with our patient exams.

Night CampPhoto By: Brandon Johnson

Last week, a BSN student had a man whose feet were so badly irritated that he was unable to walk. His feet were exposed and raw and the slightest touch caused him to have extreme pain. At the foot care station, she gently washed and treated his feet. Another BSN student braced this man and helped him walk to a chair where other students providing screening exams could walk to accommodate him. A community health assessment was completed the next day and it was discovered that his irritation was because he had holes in his shoes. Pesticides and water seeped into his shoes while he worked in the fields, resulting in prolonged moisture and irritation. The NP ordered the patient oral steroids and topical ointment.

Night CampPhoto By: Brandon Johnson

Last night, this same man returned. He was so joyous because he was able to walk. The same BSN student who provided foot care one week prior sat him down at the foot care station. The transformation on his feet was incredible. His open sores had healed and the infection had gone. He was given new shoes without holes. He was so grateful for the care that we provided and continuously thanked us. As the man left, he and the BSN student said goodbye with tears in their eyes.

Night CampPhoto By: Brandon Johnson

This experience reminded us all what nursing is truly about. It is about taking the skills that we learn and using them in a selfless manner. In the words of Maya Angelou, “As a nurse, we have the opportunity to heal the heart, mind, soul, and body of our patients, their families and ourselves. They may forget your name, but they will never forget how you made them feel.”

WOW! A relaxing weekend at St.. Simons Island what a perfect way to end an amazing and exhausting week by sleeping in, lounging on the beach and eating delicious seafood. It has refueled and recharged my mind, body and spirit and prepared me for round 2 of my MFWHP journey.

The first week was emotional, rewarding and humbling to say the least. The multi-disciplinary team provided much needed and well deserved care and services to approximately 250 migrant farmworkers from various farms throughout the past week. I can’t believe as a team we accomplished so much in what seemed like so little time. This is a true testament of what can happen when people unity for a common cause. It is this commitment, dedication and hard work that makes me proud to be an Emory Nursing student. 🙂

As I gear up for the week ahead I look forward to the smiling faces of the children at Cox Elementary School and the Men on the farms who always say “thank you” as their services are complete in which I eagerly reply “your welcome” and return the smile!!

The first week in Moultrie for the Migrant Farmworker Health Program (MFWHP) has come to an end. The best words that I could use to describe this experience thus far, is incredibly enriching. It is truly incredible to see different interdisciplinary professions working together with the common goal of providing the best care for this vulnerable population. There were students from UGA School of Pharmacy, Georgia State Physical Therapy, Darton College Dental Hygiene, and Emory University School of Nursing BSN and Nurse Practitioner students providing care this week.

We began each day at Cox Elementary School doing basic screenings for the children. This entailed height/weight/BMI, hemoglobin, glucose, hearing, vision, dental exams, physical therapy, and a visit with a nurse practitioner. Spending time with these students each day has not only providing learning experiences but also opened our hearts and eyes to the disparities young children in this area face.

Each night, we traveled to different farms throughout the Moultrie area. Some of the camps consisted of barrack living arrangements with no air conditioning. Others, like the H2A camps (which are government owned) were more suitable with air condition, enclosed showers and bathrooms, and generally more sanitary living conditions. During the night camps, we set up multiple stations for basic screenings: blood pressure, height/weight/BMI, foot care, and hemoglobin and glucose checks. The workers would then get dental exams, physical therapy, a visit with a nurse practitioner, and pharmaceutical care if needed. My personal favorite to work was foot care. There is not a more humbling experience than to provide a simple service, like foot washing, to someone who may have never or will never experience it. I am absolutely loving this experience and I am so grateful for this opportunity to provide care in a migrant health setting.

We have the weekend off, so most of our BSN class in this program headed to St. Simons Island for some rest and relaxation before gearing up for the second week in Moultrie!

It is Day 4 of my journey with the Migrant Farmworker Health Program (MFWHP) in Moultrie, GA and all I can say is “AWESOMENESS”!

The last couple of days have TRULY been amazing and filled with wonderful little children (ages 3-12) receiving screenings and services such as: anemia, hypertension, vision, audiometry, dental and physical therapy from various disciplines (i.e. Nurses, Nurse Practitioners, Physical therapist, Dental Hygienist and Pharmacist). In addition, my nights have been spent with dedicated, committed and hardworking farmworkers picking crops (i.e. jalapeno peppers, cantaloupes, cucumbers, watermelons, bell peppers, etc.,) which grace our dinner tables nightly. Therefore, to say this experience has been rewarding is an understatement.

At last night’s camp I worked in the “foot care” and LOVED IT! The worker’s feet were assessed for fungal infections, trench foot, lacerations, swelling and pain. What a “humbling experience” to provide such personal care for a very deserving population. Well, if you have not noticed thus far, let me let you in on a little secret….I am having the TIME OF MY LIFE! So with that being said, stay tuned for more updates and pictures as the MISSION continues.

Sitting here in my room trying to rest before we head out this evening. It’s pouring rain outside and I’m hoping it will go away so we can go out to the camp tonight. These last few days have been one heck of a good time, but man are we all tired! Everyday in the morning at school we are getting more stream lined with getting the kids screened. It’s been fun seeing how all of the different departments are getting to know each other more and work together. Every night more workers are coming out to get screened and helped.

Yesterday had a minor bump in this awesome experience….Got a speeding ticket trying to get back to the hotel in time to go out for a farm tour during our midday break. I was upset until I realized how small in the scheme of things that really is. Plus going to the local YMCA and doing dead-lifts for an hour helped relieve some stress too.

My classmates have been awesome these past few days with how hard they work! I am so pumped to be a part of this group of people! They work their butt off to really change these peoples lives we are helping. It’s very encouraging and motivating and helps reassure me that this is the best career in the world.

Well getting ready to go to my classmates seminar on Health disparities in adults and children before we hopefully head out tonight!